CALUMET CITY POLICE DEPARTMENT
READ CAREFULLY
The following instructions are furnished as a guide to assist you in filling out the
personal history form. This form must be completed and detailed in all respects.
It is the basis for your background investigation which will be conducted to
determine your suitability for employment with the City of Calumet City Police
Department.
ALL QUESTIONS MUST BE ANSWERED COMPLETELY AND
ACCURATELY. If a question does not apply, enter N/A in the space provided.
Falsifying or failure to include information as directed will be considered just
ground for non-acceptance, or termination if already employed. Avoid errors by
reading the directions carefully before making any entries on the form. Make sure
your information is correct and in proper sequence before you begin.
YOU ARE RESPONSIBLE FOR OBTAINING CORRECT ADDRESSES. If you
are not sure of an address, check it by personal verification. Your local library
may have a directory service or copies or local telephone directories.
Whenever a report of an incident is required, be sure that you give all facts
pertaining to it. Present the information in such a manner that any person
unfamiliar with the situation will be provided with all the details and facts in the
order in which they occur. Include the approximate dates or times the events took
place, and the names of persons or organizations involved.
If there is not sufficient space on the form for you to include all the information
required, it should be placed on the back of the sheet with the number of the
question next to the answer.
Remember, every item will be checked and must be verified. A careful, accurate,
and complete form will help to expedite your examination. All answers are to be
legible and printed in ink. You will be administered a polygraph examination to
determine authenticity of information give by you.
- INSTRUCTIONS -
CALUMET CITY POLICE DEPARTMENT – PERSONAL HISTORY FORM
PERSONAL
(To be printed legibly and in ink – Answer every question completely)
________________________________
Date Submitted
1. Your name:_____________________________________________________
First
Middle
Last
2. Social Security No: ________________________ ______________________
(Maiden Name – If applicable)
3. Give any other names you have used or have been know by, and state
reasons: _________________________________________________________
________________________________________________________________
4. Weight: _______ lbs.
Height: ________ft. ______in. Sex: ________
Age: _______
Hair Color: __________________
5. Current address: ________________________________________________
Number
Street
City
6. Current Phone no: ____________________
State
Zip
_____________________
Home
Business or Cellular
7. With whom do you reside? _________________________________________
8. Date of birth? ____________________________________________
Month
Day
Year
9. Place of birth? __________________________________________________
City
County
10. Are you a citizen of the United States?
State
YES: ________ NO: _________
- PERSONAL INFORMATION 2
CALUMET CITY POLICE DEPARTMENT – PERSONAL HISTORY FORM
MARITAL STATUS
11. Are you single, married, separated, divorced, or widowed?_________
If married please list the following information:
___________________________________________________________
City
State (where marriage was performed)
Name of present spouse and age: _______________________________
If presently separated, divorced, or annulled, provide the necessary
information below. Please list all prior marriages in the order of
occurrence.
Name of former spouse: _______________________________________
First
Middle
Last
City and state former marriage(s) performed:
___________________________________________________________
City
State (where marriage was performed)
Date
Address of former spouse:
___________________________________________________________
Number
Street
City
State
Zip
Phone number of former spouse:
_____________________________
__________________________
Home
Business or Cellular
Title of Court issuing divorce: ___________________________________
Date filed: __________________ Date granted: ____________________
- MARITAL STATUS -
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CALUMET CITY POLICE DEPARTMENT – PERSONAL HISTORY FORM
FAMILY HISTORY
12. List all children related to you, natural, step-children, adopted, foster
children, or any other dependants. If deceased, please indicate with the
date(s).
FULL NAME
ADDRESS
RELATION
DATE OF BIRTH
________________
_______________ __________ ____________
________________
_______________ __________ ____________
________________
_______________ __________ ____________
________________
_______________ __________ ____________
________________
_______________ __________ ____________
13. List other relatives in the following order: Father, Mother (include maiden
name(s), brother(s), sister(s), other legal guardians. If deceased, please
indicate with the date(s).
FULL NAME
AGE
ADDRESS
RELATION
DATE OF BIRTH
____________ ____ _______________ _________ ____________
____________ ____ _______________ _________ ____________
____________ ____ _______________ _________ ____________
____________ ____ _______________ _________ ____________
____________ ____ _______________ _________ ____________
____________ ____ _______________ _________ ____________
____________ ____ _______________ _________ ____________
- FAMILY HISTORY -
4
CALUMET CITY POLICE DEPARTMENT – PERSONAL HISTORY FORM
MEDICAL HISTORY
14. Have you ever been clinically listed or proven to have any mental or nervous
disorder(s)? YES: __________ NO: ___________
If you answered yes, please explain in detail including types and dates:
________________________________________________________________
________________________________________________________________
15. Have you ever undergone any type of psychiatric examination(s) or
treatment(s)? YES: ____________
NO: __________
If you answered yes, please explain in detail dates and all information:
________________________________________________________________
________________________________________________________________
16. Are you or have you ever received an allowance for any type of disability?
YES: ______ NO: _______ If yes, please list the nature of the disability and the
agency providing benefits: ___________________________________________
17. Do you have or have had any of the following:
Yes
Heart Condition
___
Diabetes
___
Blood Pressure Problems ___
Convulsions/Fainting
___
Back Problems
___
Hernia(s)
___
Communicable Diseases ___
No
___
___
___
___
___
___
___
Knee or Joint Problems
Knee or Joint Pains
Surgery
High Cholesterol
Head Injury
Lung Condition
Yes
____
____
____
____
____
____
No
____
____
____
____
____
____
If you have answered yes to any of the above questions, please explain in detail:
________________________________________________________________
________________________________________________________________
18. Do you have or have had any injury or illness which prevented you from
doing a particular job or caused you to take more than five (5) days off work or
school? Yes: ______ No: _____ If yes, please explain: ___________________
________________________________________________________________
19. Do you wear glasses or contact lenses? Yes: _____ No: _____ Please list
you vision without correction ________________________
20. Do you have any hearing impairments? Yes: ____ No: ____
21. Do you smoke? Yes _____ No: _____
5
22. Are you currently taking any prescription medication? Yes: ____ No: _____
If yes, please list with an explanation for use: ___________________________
_______________________________________________________________
_______________________________________________________________
23. List your family doctor’s information: ______________________________
Phone Number
_______________________________________________________________
Name
Address
City
State
24. Are you currently under a doctor’s care? Yes: ____ No: ____
If yes, please explain: ______________________________________________
________________________________________________________________
- MEDICAL HISTORY -
6
CALUMET CITY POLICE DEPARTMENT – PERSONAL HISTORY FORM
REFERENCES
25. List five people who know you well enough to provide current and past
information about you. Do not list relatives or former employers:
Name: __________________________________ Years known: _____________
Residence phone: __________________Cellular phone: __________________
Address: _________________________________________________________
Name: __________________________________ Years known: _____________
Residence phone: _________________ Cellular phone: ___________________
Address: _________________________________________________________
Name: __________________________________ Years known: _____________
Residence phone: _________________ Cellular phone: ___________________
Address: _________________________________________________________
Name: __________________________________ Years known: _____________
Residence phone: __________________ Cellular phone: __________________
Address: _________________________________________________________
Name: ___________________________________ Years known: ____________
Residence phone: ___________________ Cellular phone: _________________
Address: _________________________________________________________
- REFERENCES -
7
CALUMET CITY POLICE DEPARTMENT – PERSONAL HISTORY FORM
FINANCIAL HISTORY
26. List all current outstanding debts involving you or your spouse:
Type
To Whom
Address
Total
Payments
Open/Closed
Rent or
Mortgage
_________________________________________________________________________
Vehicle
_________________________________________________________________________
Loans
__________________________________________________________________________
Charge
Accounts
__________________________________________________________________________
__________________________________________________________________________
Credit Cards
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
Other
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
Total: __________________________
- FINANCIAL HISTORY -
8
CALUMET CITY POLICE DEPARTMENT – PERSONAL HISTORY FORM
FINANCIAL HISTORY
27. Have you or your spouse ever:
Yes
____
____
____
____
____
____
Had your wages garnished?
Been refused credit?
Been delinquent on payments?
Had any property repossessed?
Filed or declared bankruptcy?
Been sued?
No
_____
_____
_____
_____
_____
_____
If the answer to any of the above questions is yes, provide a detailed explanation
on the back of the page, including dates, location, etc.
Name of your bank: ________________________________________________
Address of your bank: ______________________________________________
Account number(s): ________________________________________________
Have you ever been refused a life, health, auto, or other insurance policy?
Yes ______ No _____ If yes, explain reason: ___________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
- FINANCIAL HISTORY -
9
CALUMET CITY POLICE DEPARTMENT – PERSONAL HISTORY
EMPLOYMENT HISTORY
28. Begin with your present or most recent job and list your complete work
record. List dates in proper sequence. When listing military service, give name
and rank of last immediate superior.
From_______ To_______ Employers Name_________________________________________
Phone Number_________________ Address _______________________________________
Duties________________________________________________________________________
Supervisor’s Name___________________ Reason for Leaving________________________
From_______ To_______ Employers Name_________________________________________
Phone Number_________________ Address _______________________________________
Duties________________________________________________________________________
Supervisor’s Name___________________ Reason for Leaving________________________
From_______ To_______ Employers Name_________________________________________
Phone Number_________________ Address _______________________________________
Duties________________________________________________________________________
Supervisor’s Name___________________ Reason for Leaving________________________
From_______ To_______ Employers Name_________________________________________
Phone Number_________________ Address _______________________________________
Duties________________________________________________________________________
Supervisor’s Name___________________ Reason for Leaving________________________
From_______ To_______ Employers Name_________________________________________
Phone Number_________________ Address _______________________________________
Duties________________________________________________________________________
Supervisor’s Name___________________ Reason for Leaving________________________
- EMPLOYMENT HISTORY -
10
CALUMET CITY POLICE DEPARTMENT – PERSONAL HISTORY FORM
EMPLOYMENT HISTORY
29. Have you ever been discharged or asked to resign from any position or
employment? YES____ NO______ If yes, please explain in detail reason and
employer: _____________________________________________________
______________________________________________________________
30. What, if any, disciplinary actions (formal or informal) have been instituted
or administered to you as an employee of any of any of the above? ________
______________________________________________________________
31. List below every civil service or public agency competitive examination
you have taken. Include any other law enforcement agencies or previous
applications with the City of Calumet City Police Department.
AGENCY
DATE OF EXAM
ACCEPTANCE
______________________________________________________________
______________________________________________________________
______________________________________________________________
______________________________________________________________
If you were not employed by any of the above agencies, give reason, if
known: _______________________________________________________
______________________________________________________________
______________________________________________________________
- EMPLOYMENT HISTORY-
11
CALUMET CITY POLICE DEPARTMENT – PERSONAL HISTORY FORM
RESIDENCE HISTORY
32. List all addresses where you have lived or stayed during the last ten (10)
years. Start with the most recent address. Do not list present address. During
military time, list all addresses off base rather than military quarters. List date
by month and year.
From________ To_________ Address_______________________________
City________________ State________________ Zip Code______________
With whom did you reside? _______________________________________
If Rental, name & address of Landlord: ______________________________
From________ To_________ Address_______________________________
City________________ State________________ Zip Code______________
With whom did you reside? _______________________________________
If Rental, name & address of Landlord: ______________________________
From________ To_________ Address_______________________________
City________________ State________________ Zip Code______________
With whom did you reside? _______________________________________
If Rental, name & address of Landlord: ______________________________
From________ To_________ Address_______________________________
City________________ State________________ Zip Code______________
With whom did you reside? _______________________________________
If Rental, name & address of Landlord: ______________________________
- RESIDENCE HISTORY -
12
CALUMET CITY POLICE DEPARTMENT – PERSONAL HISTORY FORM
MILITARY HISTORY
33. Have you ever served in a military or naval organization of the United
States? YES __________ NO __________
34. List all periods of active service in the armed forces of the United States:
Date of service: From__________ To_________ Branch ________________
Unit designation__________________ Service No. ____________________
Highest rank held_________________ Type of Discharge_______________
Date of service: From__________ To_________ Branch ________________
Unit designation__________________ Service No. ____________________
Highest rank held_________________ Type of Discharge_______________
If you have received a discharge other than honorable, please give any all
details leading to that decision:_____________________________________
______________________________________________________________
35. Military reserve status: ACTIVE__________ INACTIVE_____________
Branch of service_____________________ Unit_______________________
Address of unit__________________________________________________
Are you required to attend a period of active duty annually? YES____ NO___
If yes, how many days and list dates? _______________________________
36. Have you ever asked for or received deferment from military service?
YES____ NO____ If yes, give draft board number and location, dates, and
full details.
Address of present draft board_____________________________
Draft board number______________________________________
Selective Service number_________________________________
Classification___________________________________________
- MILITARY HISTORY-
13
CALUMET CITY POLICE DEPARTMENT – PERSONAL HISTORY FORM
EDUCATION HISTORY
37. List all high schools, colleges, universities, trade and business schools
attended. Begin with the most recent and continue in sequence.
Name
Address, City, State
From
To
Graduated Yes/No
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
38. If you attended college, what was your major_________________________?
What was your minor_______________?
Degree___________________________________________?
39. Were you ever suspended or expelled from any school? YES____ NO_____
If yes, please explain_______________________________________________
40. List any courses or training that you feel have a bearing on your qualifications
for the position____________________________________________________
________________________________________________________________
- EDUCATIONAL HISTORY 14
CALUMET CITY POLICE DEPARTMENT – PERSONAL HISTORY FORM
ORGANIZATIONAL MEMBERSHIP
41. Are you now or have you ever been a member of any organization,
movement, or group which advocated or approves the commission of acts of
force or violence to deny other persons their rights under the constitution of
the United States, or which seeks to alter the form of government of the
United States or the State of Illinois, by any lawful or unconstitutional means?
YES_____ NO_____ If yes, explain_________________________________
______________________________________________________________
______________________________________________________________
42. List all organizations you now or have ever belonged to_______________
______________________________________________________________
______________________________________________________________
- ORGANIZATIONAL MEMBERSHIP –
15
CALUMET CITY POLICE DEPARTMENT – PERSONAL HISTORY FORM
ARREST INFORMATION
43. Have you ever been arrested, detained by Police or summoned into
court? YES______ NO______ If yes, complete the following (List juvenile as
well as adult occurrences):
Crime Charged
Police Agency, City/State
Date
Disposition of Case
______________________________________________________________
______________________________________________________________
______________________________________________________________
______________________________________________________________
44. Were you ever disciplined while in the military service (include court
martial, captain’s masts, company punishment, or other)? YES___ NO____
If yes, complete the following:
Charge
Agency
Date
Age
Disposition
______________________________________________________________
______________________________________________________________
______________________________________________________________
______________________________________________________________
- ARREST INFORMATION -
16
CALUMET CITY POLICE DEPARTMENT – PERSONAL HISTORY FORM
TRAFFIC HISTORY
45. Do you possess a valid operator’s license? YES____ NO____
46. What state do you legally have an operator’s license?
____________________
47. What is your license number? ______________ Expiration date________
48. What type of license do you have? _______________________________
49. Was your license ever suspended or revoked? YES____ NO____
If yes, give date, location, and reasons: ______________________________
______________________________________________________________
50. List all driving citations you have received as an adult or juvenile,
excluding parking tickets.
Month/Year
Charge
City/State
Disposition
______________________________________________________________
______________________________________________________________
______________________________________________________________
______________________________________________________________
Describe in brief narrative any traffic accidents in which you have been
involved, giving approximate date and locations: _______________________
______________________________________________________________
______________________________________________________________
- TRAFFIC HISTORY 17
CALUMET CITY POLICE DEPARTMENT – PERSONAL HISTORY FORM
LIQUOR & NARCOTICS
51. Describe in your own words your use of intoxicating liquors______________
________________________________________________________________
52. Have you ever used or tried marijuana, cocaine, or other controlled
substances? YES_____ NO______ If yes, what were the circumstances? _____
________________________________________________________________
53. Have you ever used any form of drugs or narcotics other than those
prescribed by your physicians? YES_____ NO____ If yes, what were the
circumstances? ___________________________________________________
________________________________________________________________
54. Have you ever sold or furnished drugs or narcotics to anyone? YES___
NO___ If yes, explain in detail ________________________________________
________________________________________________________________
- LIQUOR AND NARCOTICS -
18
CALUMET CITY POLICE DEPARTMENT – PERSONAL HISTORY FORM
MISCELLANEOUS
55. If it became necessary, in the course of your duties, to take a human life,
would you have any reluctance due to religious or other beliefs? YES___
NO___ If yes, explain ____________________________________________
______________________________________________________________
56. Are there any features about police work which would be distasteful to
you? _________________________________________________________
______________________________________________________________
57. Are you now or have you ever been a party named in a civil suit,
judgment, decree, or other court litigation? YES____ NO_____ If yes, please
explain _______________________________________________________
______________________________________________________________
58. Do you know of anything that would disqualify you for police appointment
or prevent you from fully discharging official duties of said position? YES___
NO____ If yes please explain, _____________________________________
______________________________________________________________
- MISCELLANEOUS –
19
CALUMET CITY POLICE DEPARTMENT – PERSONAL HISTORY FORM
CERTIFICATION
I hereby certify that there are no willful misrepresentations, omissions, or
falsifications in the foregoing statements or answers to the questions asked. I am
fully aware that any such misrepresentations, omissions, or falsifications will be
grounds for immediate rejection or termination of employment.
_____________________
Signature of Applicant
_____________________
Date
- CERTIFICATION -
20
CALUMET CITY POLICE DEPARTMENT – PERSONAL INQUIRY WAIVER
To: _____________________________________________________________
I respectfully request and authorize you to furnish the Calumet City Police
Department any and all information that you may have concerning me, my work
record, my reputation, my financial and credit status. Please include any and all
medical, physical, and mental records or reports including all information of a
confidential or privileged nature, and photocopies of same if requested. This
information is to be used to assist the Calumet City Police Department in
determining my qualifications and fitness for the position I am seeking with the
Calumet City Police Department.
I hereby release you, your organization or other from any liability or
damage which may result from furnishing the information requested above.
_____________________
Applicant’s Signature
_____________________
Date
THIS FORM WILL BE RETAINED IN YOUR FILE
- WAIVER-
21